Provider Demographics
NPI:1912388299
Name:EAST SHORE DIAGNOSTICS INC
Entity Type:Organization
Organization Name:EAST SHORE DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAMAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MITAISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-731-9716
Mailing Address - Street 1:7506 16TH AVE
Mailing Address - Street 2:STE2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1064
Mailing Address - Country:US
Mailing Address - Phone:818-731-9716
Mailing Address - Fax:
Practice Address - Street 1:7506 16TH AVE
Practice Address - Street 2:STE2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1064
Practice Address - Country:US
Practice Address - Phone:818-731-9716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile